Augmentation of temporal hollowing has become a popular aesthetic procedure. While synthetic fillers and fat offer simplicity, they do not create a permanent treatment solution. Temporal implants fill that need and can be placed through a relatively minor surgical procedure.
The first generation standard temporal implants are of a soft flexible silicone material that is designed to simulate muscle tissue. It has a shape that simulates the lateral orbital rim anteriorly, the zygomatic arch inferiorly and then tapes superiorly and laterally into a tapered edge. It is longer horizontally than vertically and is designed to treat the deepest part of temporal hollowing which is at the lower half of the anterior temporal region between the eye and the temporal hairline.
But some patients have temporal hollowing that extends up higher and desire a temporal augmentation effect that is vertically longer. In these cases the standard temporal implant can be rotated 90 degrees so that it is placed with the longer horizontal part vertically and the vertical part horizontal. It is also important that the right and left temporal implants be switched when making this implant re-orientation. In other words, a right temporal implant is used on the patient’s left side that is rotated 90 degrees in orientation n the left temporal hollow.
The standard temporal implant offers some versatility in how it can be used to create its temporal augmentation effect. In the subfascial location, it offers two options for the extent of its effect based on how the implant is oriented.
Temporal augmentation has been a popular cosmetic procedure due to the use of synthetic injectable fillers and fat grafting. Such injection techniques make it easy to treat undesired temporal hollowing of varying degrees. By none of the injection materials are perfect and most will eventually dissolve and their benefits lost with the exception of fat. Fat grafting can be a permanent method of temporal augmentation but such an outcome is far from assured.
A synthetic temporal implant is a new type of facial implant designed to augment the temporalis muscle and treat temporal hollowing. It is a very soft implant that is inserted through a small scalp incision in the temporal hairline and placed under the temporalis fascia between the temporal hairline and the lateral orbital rim. It is a very effective procedure that has a minimal recovery and provides permanent temporal augmentation.
As temporal augmentation as progressed it has become apparent that temporal augmentation is not as simple as just augmenting the temporal hollowing just above the zygomatic arch. (Zone 1 anterior temporal region) While the deepest part of a temporal hollowing (concavity) is at its lowest end, some patients desire temporal augmentation all the way up to the temporal line at the side of the forehead. This high temporal area (Zone 2 anterior temporal region) is not covered by the first generation standard temporal implant.
An extended temporal implant has been developed to address both Zone 1 and Zone 2 anterior temporal zone deficiencies. It has been designed to augment from the zygomatic arch all the way up to the side of the forehead. (temporal line) It is fairly thin (3.5mms) at its greatest thickness but does not need to be very thick when augmenting a long vertical area.
The extended temporal implant is placed through the same vertical temporal scalp incision as the standard temporal implant. It is also placed below the fascia on top of the temporalis musle. Its superior edges are very thin to prevent any visible ridging in the thin upper temporal tissues.
The extended temporal implant provides another facial augmentation option for more severe and extensive temporal hollowing defects. Its effectiveness and simplicity makes it an attractive alternative to injectable fillers and fat.
Augmentation of the temporal region is a new area for synthetic facial implants. While every other facial implant designed is for bony augmentation, temporal implants provide enhancement of the soft tissue (muscle) region of the side of the forehead and eye. While injectable filler and fat provide a less invasive approach, they do not offer the capability of producing a one-time permanent solution to temporal hollowing.
The concept of a temporal implant comes from the historic repair of zygomatic arch fractures. Known as a Gille’s approach, depressed arch fractures are elevated from an incision in the hair-bearing temporal region and approached in a subfascial manner down to the bone. The path of dissection is on top of the muscle but under the fascia. It can be seen with the instrumentation that the entire temporal contour can be elevated from below. Thus it was logical to assume that an implant placed in the same location staying above the zygomatic arch would have an augmentative effect. The overlying temporal fascia seems flexible enough and the underlying temporalis muscle stout enough that the implant can push outward rather than inward.
The subfascial plane for a temporal implant is an easy one to surgically approach. And introducing the implant is equally easy. But one question that often comes up is what is to keep the implant from sliding down along the temporalis muscle, below the zygomatic arch and into the lower face? Not only has it never occurred but there are multiple anatomic reasons as to why that can not happen.
The first reason temporal implants have pocket stability is the anatomy of the subzygomatic arch space. While the bony arch does create a space or hole beneath it, the actual dimensions of the created space are less than the width of a temporal implant. As the zygomatic arch curves inward to attach to the temporal bone, it narrows the subzygomatic arch space. Thus when looking from above it can be seen that the front to back length of this space is shorter than the anteroposterior length of a temporal implant.
The second bony reason is the location of the coronoid process of the mandible. The tip of the coronoid process acts as an inferior stop as it juts upward into the subzygomatic arch space. In addition, onto the coronoid process are the funneled attachments of the temporalis muscle which also creates a soft tissue block.
For these anatomic reasons the temporal implant is prohibited from falling downward into an unintended anatomic location. The surgeon should feel comfortable making a pocket that is felt to be best for implant placement without this concern.
Temporal augmentation with implants is done by inserting them through a small vertical incision in the temporal hairline. They are placed on top of the muscle but below the overlying fascia. They are composed of a very soft and flexible silicone material that feels like soft tissue (muscle or fat) and not hard like bone. Different shapes and thicknesses of implants are available to best fill out esch patient’s temporal defects.
The following postoperative instructions for temporal implants are as follows:
1. Most temporal implant procedures have no discomfort. Patients usually only feel the need to use Tylenol or Ibuprofen for just a few days after the procedure, if any medication at all. You may also feel free to use ice packs on the temples for discomfort relief and swelling reduction the first night after surgery if you desire.
2. In all cases of temporal implants, there will be a circumferential wrap around the head for the first night after surgery. You may remove this wrap the day after surgery. It does not need to be used thereafter.
3. The sutures used in the incision in the temporal hairline will be dissolveable. There is NO need to apply antibiotic ointment on them. They require no topical care.
4. You may shower as normal the following day and you may wash your hair as normal 48 hours after surgery. There is no harm in getting the temporal suture lines wet.
5. Temporal implants may cause some swelling and bruising the eyelids or cheeks in some patients. You may was your face and apply make-up over any bruised areas the following day.
6. There are no limitations to any physical activities after temporal implant surgery. You may feel free to run, workout and do any non-contact sporting activity as soon as you feel comfortable.
7. You may eat and drink whatever you like right after surgery.
8. You may drive the next day after surgery when you feel comfortable and are not on any pain medication.
9. You may wear regular or sunglasses when the temporal swelling permits and it feels comfortable to do so.
10. If any temporal redness, increased tenderness or swelling, or incisional drainage develops after the first week of surgery, call Dr. Eppley and have your pharmacy number ready.
Every plastic surgery procedure has numerous issues that every patient who is undergoing a procedure should know. These explanations are always on a consent form that you should read in detail before surgery. This consent form, while many perceive as strictly a legal protection for the doctor, is actually more intended to improve the understanding of temporal implant augmentation. The following is what Dr. Eppley discusses with his patients for this procedure. This list includes many, but not all,of the different outcomes from surgery. It should generate both a better understanding of the procedure and should answer any remaining questions that one would have.
Alternatives for improving the appearance of a depressed or hollowed temporal area include synthetic injectable fillers, fat injections, or augmentation using a variety of bone cements.
The goal of temporal augmentation is to improve its appearance from a hollowed (concave) profile to a flatter one. In rare cases, the patient may even have a more convex profile if they desire.
The limitations of temporal augmentation with implants is the size and shape of the implanted material. The thickness of the implant and its height and length determine how much augmentation is achieved.
Expected outcomes include the following: temporary swelling and bruising around the temples and eyes, temporary numbness of the overlying temporal skin, and four to six weeks after surgery to see the final temporal shape.
Significant complications from temporal implants are extremely rare. More likely risks include infection, permanent temporal hairline scars, overcorrection or undercorrection of the temporal profile, and implant/augmentation asymmetry. Any of these risks may require revisional surgery for improvement.
Should additional surgery be required for temporal implant revision and/or replacement, this will generate additional costs.
There are a large number of available implants that seemingly provide aesthetic augmentation for every conceivable facial location. Most facial implants are made of a soft flexible silicone elastomer material whose physical properties allow them to be relatively easy to surgically place and remove if necessary. Also, a silicone elastomer material allows for any size and shape of a facial implant to be made at an economical cost.
While most sites of facial implant augmentation are done to augment skeletal convexities and concavities, facial soft tissue augmentations can be desired as well. One such soft tissue area is that of temples. The aesthetic boundaries of the temples is bounded by four sides, the anterior temporal hairline, the top part of the zygomatic arch, the lateral wall of the orbit and a small portion of the lateral forehead. The contour of the temples is either flat or slightly concave. This contour is controlled by the thickness of the underlying temporalis muscle and fat pad and not by the temporal skull bone as if often thought.
When the temples are excessively concave (sunken in), treatment is often sought for augmentation. Most temporal augmentations are done by injections of either synthetic materials (IJuvederm, Radiesse, Sculptra) or fat. While an injectable temporal augmentation approach can be effective, they often have to be repeated for maintenance of the augmentative effect. Fat injections can also be unpredictable in terms of volume survival and may also have to be repeated to create a more pronounced and/or more prolonged effect.
For a permanent effect, a new silicone implant is now available for aesthetic temporal augmentation. (Temporal Shell Implant, Implantech, Ventura, CA) Composed of a very soft and low durometer silicone material, it feels very similar to muscle or fat tissue. Its shape matches the typical borders of the temporal region. It is thicker at its bottom portion where more augmentation is needed and has upper feathered edges to blend into the upper temporal area without visible edge demarcation. As a soft tissue implant, it should be placed under the temporalis fascia on top of the temporalis muscle through a small vertical incision in the temporal hairline. While it can be placed on top of the temporalis fascia, there are increased risks of implant visibility and injury to the frontal branch of the facial nerve.
Temporal Shell implants are currently available in two sizes. The implants have radiating lines on them, not only for flexibility, but also for implant shaping if needed. Scissors can be used to quickly shape and customize the implant for any patient’s temporal dimensional needs.
Temporal implant augmentation is very straightforward and could be even be done under local or sedation anesthesia. Subfascial pocket dissection is rapid and risks no injury to any blood vessel or nerves. There is very little swelling and usually no bruising after the procedure. Patients report no pain afterwards.There are no physical restrictions or care needed after surgery.
Temporal Shell Implants are now available to provide permanent soft tissue augmentation for aesthetic concave deformities of the temporal region. They can be used when either an injectable temporal augmentation has failed or a more assured one-time permanent effect is desired. The implants are uniquely made to create a soft tissue effect rather than a more firm bony augmentation commonly used for facial skeletal augmentation.
One of the last facial areas to be cosmetically enhanced is that of the temples. Not to be confused with places of worship and even having slightly different Latin word derivations, the temples anatomically are to the side of the eye along the side of the head. Aesthetically, it is a near isosceles triangle with the lower horizontal border of the zygomatic arch, the anterior border of the lateral orbital wall and the angulated posterior border of the temporal hairline. It usually has a very slight depression if a plumb line is laid across any of its borders. Temporal hollowing is judged to occur when the depression becomes greater than a few millimeters. Temporal bulging, which is much more rare, is when the underlying muscle pushes outthe skin beyond the projection of its borders. Temporal hollowing can occur because of genetics, extreme weight loss, medications and certain diseases, all creating resorption of the temporal fat pad. Temporal hollowing is treated today by injectible synthetic fillers and fat grafts and a variety of performed synthetic implants and allogeneic materials placed through a small incision in the temporal hairline.
Soft tissue augmentation of the face has gained popularity due to the use of a wide diversity of injectable fillers. From synthetic materials to fat, any soft tissue zone of the face can be injected. While facial implants have been around for many years for hard tissue augmentation, such as the chin, cheeks and jaw angles, there are many more soft tissue zones than there are hard tissue ones.
One of the facial soft tissue zones that has become possible to reliably treat is that of the temples. The temporal zone is very much like the submalar-lateral facial zone in that it is a ‘trampoline’ facial zone. It is surrounded by bony margins that support skin and underlying fat and muscle. The superior margin is the anterior temporal line, the transition area into the bony forehead. Its anterior margin is the lateral orbital wall and its inferior border is the zygomatic arch. Its posterior border is not significant in most cases because it is obscured by the hairline and temporal scalp.
The contour shape of the temples is primarily influenced by how much fat and muscle lies underneath. Skin laxity is not an issue. Most commonly there is a slight concavity to the temples. But too much concavity or even excessive convexity is obvious and disrupts the shape of the overall face. How much temporal concavity is aesthetically acceptable is a matter of debate and belies any known established measurements. But when excessive the bony margins become obvious and presents an appearance of aging or even illness.
I have observed that placing a ruler or straight instrument between the anterior temporal line and the zygomatic arch, most people will have 1 to 3mms of concavity at the central or deepest area of the temples. When it exceeds 5mms or more, most people would view it as excessive temporal concavity.
For temporal hollowing, the most common treatments to date are injectable fillers. Treatment options include hyaluronic acid, PLLA and HA fillers as well as fat injections. Most of these injectable fillers are placed in the subcutaneous space between the skin and the superficial temporalis fascia. While this is where the frontal branch of the facial nerve passes, the risk of injury is low. Some do place fillers directly under the fascia into the temporalis muscle but this is less commonly done. In theory the muscle is a better place for longevity of fillers, particularly that of fat, but the push on the skin from under the temporalis fascia is weakly transmitted because the stiffer fascia pushes back against the soft filler.
While injectable fillers can be effective for temporal hollowing, they are not permanent and the volume needed for a single treatment is costly. It usually takes 2ccs of filler per side to have a visible effect. An alternative treatment for temporal hollowing is that of a synthetic implant. Made out of a flexible and very soft silicone material, temporal implants are inserted under the deep temporal fascia. It produces a result that is more significant that any injectable filler treatment and will create a permanent augmentation.
The surgical technique for placement of a temporal implant is very simple and can be done under local anesthesia if desired. Through a small vertical incision in the temporal hairline, the deep fascia is incised and the pocket quickly and easily made. Different sizes of temporal implants exist depending upon the depth of the concavity and the use of preoperative sizers. Adjustments to implant size can be easily done by trimming with scissors. There is no need for implant fixation as the pocket on top of the muscle controls its position. There is minimal discomfort afterwards and no bruising. The swelling is mild and there is no discomfort on chewing.
The simplicity and the permanence of specific shapes of synthetic facial implants should be considered as an option for the treatment of aesthetic temporal hollowing.
A recent news story out of the UK in London headlined the transfer of fat from a man’s stomach to his head to reshape it. Given that fat injections to the face, breast and buttocks have become so popular over the past decade, such a story is at the very least noteworthy.
The patient was a young 32 year-old man had some of his skull removed and surgery to reconstruct a shattered eye socket, cheekbone, and leg, following injuries sustained when he fell while climbing up a drainpipe outside his house. To ease brain swelling caused by his fall, a piece of his skull was initially removed which is standard practice in these type of injuries. Also he had titanium plates inserted to fix his broken eye socket and hold the bones together.Six months after his initial injury, the missing piece of his skull was reconstructedwith a computer-generated titanium plate based on the shape of his opposite normal skull. Despite restoring the bony shape of the skull, his temple area still remain indented. This is common after such skull procedures as the temporalis muscle, which needs to be raised off of the bone to perform the procedure, will shrink down in size during the healing process.
This ‘temporalis muscle atrophy after a craniotomy’ is well known and has been treated over the years by many methods. In this patient’s case, the surgeons used stomach fat harvested by ljposuction which was then injected into the temporal skull defect to fill it out for a smoother contour. How well the fat survived and adequately reconstructed the temporal defect months later was not described in the news story.
Reconstruction of a cosmetic temporal defect can be done with either a synthetic implant, allogeneic tissue grafts or fat injections. There are advantages and disadvantages to any of these approaches. Fat injections, just like they do for every other face and body application, offers a minimally-invasive procedure with a cannula harvest and a needle injection technique. Its disadvantage is in how much of the injected fat will survive. Experiences with temporal fat injections vary widely with some reporting good volume retention and others near complete absorption. I have seen both outcomes in my temporal augmentation with fat. For assured temporal augmentation results, a simple insertion of a specially-designed silicone temporal implant provides a permanent solution.
The temporal region of the face, technically the side of the head, occupies an often overlooked aesthetic area. It is bounded superiorly by the anterior temporal line of the forehead, anteriorly by the lateral edge of the bony brow and eye socket, inferiorly by the zygomatic arch and posteriorly by an indistinct margin in the temporal scalp hair. It is not a bony-supported region by rather one of soft tissue, the temporalis muscle and the deep fat pad. The temporalis fasciacovers the muscle and acts like a taut trampoline attached to the surrounding bony edges.
The aesthetic shape of the temple is determined by whether it has a convex, flat or concave appearance. There is no uniform standard or anthropometric measurement to judge what is its ideal shape. A flat or slightly concave temple area appears most common. A bulging or overlying convex appearance is unusual and unappealing and is rarely seen. An overlying concave appearance suggests a sickly or ill appearance. The shape and prominence of the forehead also influences how concave the temporal region will appear.
The most common aesthetic deformity of the temporal region is excessive concavity or depression. It can be caused from surgery (temporalis muscle wasting after a craniotomy), a medical condition (fat atrophy from extreme weight loss or medications) or one’s natural genetics. (congenital lipoatrophy) Regardless of its etiology, some form of an implanted material is needed to build out the temporal depression.
Methods for temporal augmentation have included injected fat, dermal grafts, bone cements or cranioplasty materials and various synthetic implants. Each has their own advantages and disadvantages and have different locations of placement, either above the fascia, below the fascia, intramuscular or on top of the temporal bone. Depending upon the cause for the temporal deformity, there may be benefits to one method of augmentation over the other.
While differing synthetic materials have been used, there has not been few if any preformed temporal implants available. A new preformed temporal implant is now available made out of flexible silicone rubber. Its shape mirrors the natural contours of the inferomedial bony boundaries where the greatest temporal concavity occurs. Its beveled shape allows differential augmentation to be achieved in an anteroposterior dimension so the augmentation is not too excessive near the hairline. Two different sizes are currently available.
Besides the innate flexibility of silicone, the implant is also designed with cross-cut ridges of material underneath to allow even greater three-dimensional implant adaptability. This could be a useful feature to allow the implant to not impede the excursion of the temporalis muscle with mastication.
In aesthetic augmentation, a temporal implant is best placed in the subfascial plane. This is easily done by a small vertical incision in the temporal hairline. This location allows the implant to be placed in a position that maximizes its shaped design. The curved form of this new temporal implant allows it to be rotated in through an incision that is smaller than its widest part. It can also be placed above the fascia but this places the frontal branch of the facial nerve at risk.
In augmentation of temporal defects from craniotomies, the temporalis muscle may be very scarred or severely atrophied. Placing it under the temporalis muscle in these craniotomy-induced defects may be preferable.
This new implant offers another treatment option for temporal hollowing. Its unique shape, flexibility and well-established tolerance to the material is a welcome addition to the expanding number of available cranial and facial implants.
Dr. Barry Eppley is an extensively trained plastic and cosmetic surgeon with more than 20 years of surgical experience. He is both a licensed physician and dentist as well as double board-certified in both Plastic and Reconstructive Surgery and Oral and Maxillofacial Surgery. This training allows him to perform the most complex surgical procedures from cosmetic changes to the face and body to craniofacial surgery. Dr. Eppley has made extensive contributions to plastic surgery starting with the development of several advanced surgical techniques. He is a revered author, lecturer and educator in the field of plastic and cosmetic surgery.